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AMERICANS who have had a stroke or a hip replacement
take for granted that they’ll need a few weeks or months
of rehabilitation to relearn speech or movement and to
figure out how to care for themselves. But when people
have a major heart problem, more often than not they
leave the hospital with nothing more than a bottle of
aspirin and a couple of prescriptions.
They
receive very little training and education in how to
eat, exercise, manage stress and otherwise pick up their
lives and care for their damaged tickers. A study in the
journal Circulation found that among 267,427 Medicare
recipients who had suffered a heart attack or had
coronary artery bypass surgery, only about 18 percent
had even one session of cardiac rehabilitation within a
year of their hospital discharge.
About
1.2 million people suffer a heart attack each year
(about 40 percent of them die), and about half a million
of them have had a previous heart attack, according to
the American Heart Association. For more than a decade,
evidence has been accumulating that cardiac
rehabilitation can reduce the risk of death from a
second heart attack by as much 30 percent.
Called
secondary prevention, rehabilitation after a heart
attack or other serious cardiac problem is designed to
reduce the risk of further heart damage, or even death,
while the patient returns to a life as normal as
possible. It provides heart-strengthening, supervised
exercise, along with nutrition and stress counseling and
social support.
A review
of studies in the May 15, 2004, American Journal of
Medicine found that patients who had exercise-based
rehabilitation for heart disease had greater reductions
in blood pressure and total cholesterol and lived longer
than patients who did not receive rehabilitation. The
American Heart Association, in a 2002 scientific
statement, calls rehabilitation the best way to provide
education, counseling and behavioral interventions to
reduce future risk.
Medicare
and most private insurers pay for rehabilitation
therapy. Yet, in most of the country including
California,
fewer than one in five heart patients receive such
services. For some, it’s because their physicians never
wrote a referral. Others obtain the referral but never
follow through.
Patty
Block of Long Beach, California, is one who has decided
cardiac rehabilitation is worth her time, despite the
responsibilities of helping to care for her husband, who
has Parkinson’s disease, as well as her 96-year-old
mother. Following her heart attack in 2007, she went to
the Long Beach Memorial Medical Center Cardiac
Rehabilitation Center for one-hour sessions three times
a week.
“I’m 67,
and I’m just not ready to have my heart go out on me
now,“ she says. She had nutrition counseling and began
learning how long, and at what pace, to walk on the
treadmill and pedal on the stationary bicycle, all the
while hooked up to an electrocardiograph whose squiggly
readings were monitored by a nurse.
The use
of this therapy varies dramatically in the United
States, according to the recent Circulation study. With
only 6.6 percent of heart patients receiving
rehabilitation, Idaho has the lowest rate of follow-up
therapy in the country;
Nebraska,
with 53.5 percent of heart patients receiving the
therapy, has the highest rate.
Researchers were at a loss to explain the wide
geographic variations in follow-up therapy. “It’s
recommended more vigorously in some parts of the
country, particularly the Midwest,” says Donald Shepard,
an author of the study and professor of health policy at
Brandeis University. It could be that medical training
in some areas promotes prevention more than in other
areas, he said, though the study didn’t address that.
How hard
a doctor pushes for rehabilitation is the best predictor
of whether a patient will follow up, according to
research published in the May 1992 issue of Archives of
Internal Medicine. Dr. Philip Ades, director of cardiac
rehabilitation and preventive cardiology at the
University of Vermont College of Medicine, is an author
of the Circulation study. He was also the lead author of
the 1992 study in which he asked 262 heart patients 62
and older to rate how strongly their doctor recommended
cardiac rehabilitation. “If the physician was strong in
recommending rehabilitation, 70 percent of patients
participated,” he says. “If it was a weak
recommendation, only 2 percent participated.”
In New
York, the referral rate to cardiac rehabilitation is
about 13 percent, says Murray Low, director of cardiac
rehabilitation at four hospitals in New York and
Connecticut, and president of the American Association
of Cardiovascular and Pulmonary Rehabilitation. “Do you
realize how outrageous that is?” he says. “We spend
millions putting in stents, bypassing arteries. And then
we say, `See you in six months.’ The patient goes home
and leads the same lifestyle that led to the problem in
the first place.”
There
are other barriers to the therapy, says Dr. Randal
Thomas, director of the Cardiovascular Health Clinic at
the Mayo Clinic. Some patients aren’t aware of the
benefits of rehabilitation; others see it as little more
than a gym membership; and some simply would have to
travel too far to reach a center. “The benefits of
cardiac rehabilitation are on the same level as aspirin,
beta blockers and statins—about a 30-percent reduction
in mortality,” Thomas said.
Dr.
Henry Van Gieson, a
Long Beach
cardiologist, says he recommends cardiac rehabilitation
for almost all of his heart attack and bypass patients.
After a heart scare, “patients start seeing themselves
as fragile and vulnerable,” he says. “When you see a
patient in your office a week or a month later, there’s
no way you can do an adequate job of doing all of the
counseling they need. This is a great way to take that
first step back to recovery.”
One of
his patients, Maurice Greeson, 65, of Long Beach, makes
twice-weekly trips to Long Beach Memorial. He has used
up his insurance coverage of cardiac rehabilitation,
following bypass surgery in February 2006, but continues
the therapy, paying $45 a month himself. “This was a
lifestyle change, big time,” he says. |
